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Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT 9 zq y4V1vLs0i.Blue Filpe PERMIT NO. .
2.YelAa �/
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING{office use)
isY7 B'MO k5i Jov-& 55 37a, R2 S��
LEGAL DESCRIPTION(office use only)
LOT / LOCK / ADDITION G /(/K./4- A-cl Add PID 075— 367- 49/0p
OWNER //,
(Name) U C us o S O v\ (Phone) b\a- 69 5 - IL)
(Address)
APPLICANT CULLIGAN WATER CONDITIONING
(Phone)
(Name) 6030 CULLICGAN WAY
(Address) MINNETONKA, MN 55345
(Addre Q 2) 933-7200 (City) (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNATURE DATE ci - I S- I
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavatory(Bathroom Sink) Stand Pipe(Washing Machine)
Laundry Tray(1 or 2 compartment sink Sewage Ejector
Shower Stall Backflow Assembly
Sinks Backflow Assembly Test
Bar Sink Lawn Sprinkler
Water Closet(Toilet) Other
FEE SCHEDULE
Industrial,Commercial&Multi-family 1%of job cost with a$49.50 minimum Residential,New One&Two-Family $149.50
Residential,Additions&Alterations $49.50
Estimated Cost $ Building Permit#
PLUMBING PERMIT FEE $
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ 511 5D
(Office Use Only)
This Application Becomes Your Building Permit When Approved id b
s Receipt No/ ,_/aR
y
Buildinc Official Date Date/ B S
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24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372